Anne Fagot-Largeault

Predicting outcome in ICU patients

ConclusionsConsiderable time and energy has been invested in the conception, modelling and evaluation of sophisticated severity scoring systems for ICU patients. These systems are created to enhance the precise estimation of hospital mortality for large ICU patient populations. Their current low sensitivity precludes their use for predicting out-come for individual ICU patients. However, severity scores can already be valuable for predicting mortality in groups of general ICU patients, and are very useful in the clinical trial setting.Outcome of ICU therapy, however, should incorporate more than mortality. Morbidity, disability and quality of life should also be taken into account; these factors were not taken into consideration in the design of the currently available severity scoring systems.At present, the severity scores have a very limited or no role in clinical decision-making for an individual patient, because they are based on a number of physiological and disease-oriented variables collected during the first 24 h after ICU admission. Future developments and subsequent validation of the dynamic process of clinical, physiological and organ-specific variables could improve the sensitivity and the value of severity scoring. Further collaborative developmental work in this field should be encouraged and supported across Europe and North America.

On Medicine’s Scientificity—Did Medicine’s Accession to Scientific ‘Positivity’ in the Course of the Nineteenth Century Require Giving up Causal (Etiological) Explanation?

Both Jose Luis Peset [25] and Dietrich von Engelhardt [11] raise a question about the nature of the conceptual ‘turn’ through which medicine is seen as a ‘positive’ science in the nineteenth century. I shall concentrate on that question.

The place of words and numbers in psychiatric research

In recent decades, there has been widespread debate in the human and social sciences regarding the compatibility and the relative merits of quantitative and qualitative approaches in research. In psychiatry, depending on disciplines and traditions, objects of study can be represented either in words or using two types of mathematization. In the latter case, the use of mathematics in psychiatry is most often only local, as opposed to global as in the case of classical mechanics. Relationships between these objects of study can in turn be explored in three different ways: 1/ by a hermeneutic process, 2/ using statistics, the most frequent method in psychiatric research today, 3/ using equations, i.e. using mathematical relationships that are formal and deterministic. The 3 ways of representing entities (with language, locally with mathematics or globally with mathematics) and the 3 ways of expressing the relationships between entities (using hermeneutics, statistics or equations) can be combined in a cross-tabulation, and nearly all nine combinations can be described using examples. A typology of this nature may be useful in assessing which epistemological perspectives are currently dominant in a constantly evolving field such as psychiatry, and which other perspectives still need to be developed. It also contributes to undermining the overly simplistic and counterproductive beliefs that accompany the assumption of a Manichean “quantitative/qualitative” dichotomy. Systematic examination of this set of typologies could be useful in indicating new directions for future research beyond the quantitative/qualitative divide.

The Influence of Genetics on Contemporary Thinking

This volume reflects on the effects of recent discoveries in genetics on a broad range of scientific fields. In addition to neuroscience, evolutionary biology, anthropology and medicine, contributors analyze the effects of genetics on theories of health, law, epistemology and philosophy of biology. Social and moral concerns about the relationship between genetics, society and the individual also figure prominently. Genetic discoveries fuel central contemporary public policy debates concerning, for example, human cloning, equitable access to healthcare or the role of genetics in medicine. Perhaps more fundamentally, advances in genetics are altering our perception of human life and death.An interview with Francois Jacob by Anne Fagot-Largeault opens the volume. In this interview, Jacob, who shared a Nobel Prize with Andre Lwoff and Jacques Monod for their discoveries concerning genetic control of enzyme and virus synthesis, addresses many of the central methodological epistemological and ethical questions covered in the volume. The dynamic interdisciplinary character of this volume makes it relevant to scholars from many disciplines, from biology, philosophy and the social sciences.

Ownership of the Human Body: Judicial and Legislative Responses in France

This essay is meant to be informative more than argumentative. The author does not express her own opinions but tries to sketch the so-called ‘French law and ethics’ of the identity relation between the person and his/her body, implying the principles of immunity or inviolability (‘immunite’) and unavailability or indisposability (‘indisponibilite’) of the human body, with the consequence that therapeutic or other uses of human blood or body parts should be non-profit. Of course, dissenting opinions have been expressed in France, but on the whole a broad consensus seems to exist, and it is expected that Parliament will pass further ‘legislation on bioethics’ systematizing the doctrine in law [34,35,36].

Epistemological Presuppositions Involved in the Programs of Human Research

The present paper addresses the question whether there are areas of conflict between currently accepted standards of scientific research in the biomedical and social sciences and ethical standards implying a respect for human beings. One may view it as a conflict between two ethics: an “ethics of knowledge” (objective truth is the highest value) and an “ethics of beneficence” (one should seek the good for mankind); or as a conflict between two conceptions of science: “pure” science, and “other” science.

Reflections on the Notion of ‘Quality of Life’

The notion of “quality of life” is very much in the air these days. The reflections that follow consider it from the medical point of view (“health-related quality of life”: HQL). Let me offer an example. Concerning the treatment of chronic diseases it is no longer enough to prove that a new therapy is effective and non-toxic; it has to be proved that in the case of efficacy and toxicity comparable to those of standard treatment, the new treatment gives the patient an improved quality of life. Thus, for instance, arterial hypertension (AHT) can easily be controlled by a variety of drugs that have little toxicity at effective dosage levels but have side-effects (nightmares, diminished sexual capacity, depression) which are often so difficult to bear as to cause the abandonment of treatment. During the past ten years, great effort has been devoted — with the aid of the pharmaceutical industry — to attempt to ascertain what therapies offer a technically satisfactory treatment of AHT without involving a deterioration in quality of life [see, e.g., 11].

Médecine et philosophie morale (1990–2010)

In a context of anxiety as for the scientific progress, early bioethics did focus on moral topics: when new biomedical techniques are scientifically possible, does it mean that they are morally grounded? Early bioethics thus widely took shape around strong collaborations between medicine and moral philosophy, and admitted a subordination of the legal and practical rules to the moral standards (respect the human dignity for example), by opposition to the social or scientific standards. But with the emergence in bioethics of new trends, carried by sociologists and philosophers claiming for a new understanding of bioethics as social or political issues, the subordination of the legal and practical rules to the moral standards is widely discussed. In this context, the moral nature of bioethics is challenged: given the importance of issues around social justice and democracy in health, considering the increasing matters of conflicts of interest, doesn’t bioethics call rather a social or political reflection? The present article is focused on these topics. It examines, through an epistemological standpoint, recent developments between moral philosophy, medicine, sociology and politics in biomedical field.

Bioethics in France: 1991–1993

During the 1991–1993 period in France, legislative action on bioethics by Parliament has been in the foreground. The National Advisory Ethics Committee for Life and Health Sciences (CCNE: “Comite Consultatif National d’Ethique pour les sciences de la vie et de la sante”) gained a new President, Jean-Pierre Changeux, in 1992 and celebrated its tenth anniversary in 1993. The regulation of human research, following the 1988 law “on the protection of persons undergoing biomedical research” [77] and the establishment in 1990–1991 of 57 regional Committees (review boards: “CCPPRB”) to assess research projects, was carefully evaluated with a view to emending and improving the law. The proceedings of the International medical ethics congress held in Paris in early 1991 appeared ([95]; see analysis in [50], § V, A, 1). The group of five persons (MM. Got, Gremy, Hirsch, Tubiana, Dubois) who had previously suggested [59] several of the key reforms that were made during the 1980s in the field of public health (or that remain to be made) evolved into a “Haut-Comite de la sante”. But the main feature of the period was the considerable effort made to “turn ethics into law” [47], i.e., to define a common legal and institutional framework within which new techniques in biology and medicine should develop. The CCNE itself had suggested in 1988 that reflection in the field of bioethics should be given “official legitimacy”.

Bioethics in France: 1989–1991

In France, the awareness of problems in the field of bioethics intensified in the early 1980s. The National Consultative Ethics Committee for Life and Health Sciences (CCNE) was created in 1983 and became operational in 1984. The issues most discussed at that time were those raised by new modes of procreation: hired wombs, substituted or multiple parenthood, and the status of frozen embryos. During the period 1989–1991, discussion of those issues has been less volatile, largely as a result of an ongoing public debate. At the same time, other less spectacular issues have been raised, such as preservation of genetic resources within the biosphere and the legitimacy of cognitive research on human beings. In the meantime, the French Parliament has engaged in legislative action.